Download - Aac Plus Intro
-
8/16/2019 Aac Plus Intro
1/42
© RCSLT 2009
Resource Manual forCommissioning andPlanning Services for
SLCN
Professor Pam Enderby
Dr Caroline PickstoneDr Alex John
Kate FryerAnna Cantrell
Diana Papaioannou
-
8/16/2019 Aac Plus Intro
2/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
2
Acknowledgements
The RCSLT and the Project Team would like to thank all those who assisted in drafting this
guidance. We have received valuable advice from many reviewers from within the speech and
language therapy profession who have given up their time generously. Experts on particular topic
areas from related professions have also been consulted and assisted with detail. Service
Commissioners and senior managers have commented on drafts showing patience and fortitude!
We would particularly like to thank the many who contributed to the focus groups which helped to
shape this document.
-
8/16/2019 Aac Plus Intro
3/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
3
Resource Manual for Commission ing and Planning Services for SLCN
CONTEXT
The aim of this section is to set out the context for this resource. This work forms part of a
range of tools which can support leaders with service planning and delivery, in line with
both government and local priorities.
It is essential for service providers to demonstrate quality and productivi ty and to:
show value for money
be able to provide a strong financial argument for the need to invest in services for
people with speech, language, communication and swallowing needs
demonstrate improvements in outcomes for individuals, families and society
Value for money is not about being the cheapest option but about delivering the most
return (impact, best outcomes) for a given investment over time.
The key drivers for change to services include:
1. The broad context, which can be divided according to the following factors:
Political and Legislative factors
Economic factors
Social factors
Technological factors
2. The near or local context, including:
Localised policies
Addressing local needs Service provision
Workforce
The evidence base
THE BROAD CONTEXT (MACRO-ENVIRONMENTAL ANALYSIS): FACTORS FROM
THE WIDER WORLD
The Macro-environmental analysis commonly takes the form of a PEST analysis:
Political and legislative factorsEconomic factors
Social factors
Technological factors
Political and legislative drivers
Devolution has resulted in changes to the powers of the different institutions across the
UK.
The government in power at Westminster maintains responsibility for policy and legislation
in relation to key areas including: tax, benefits, foreign affairs, international development,
-
8/16/2019 Aac Plus Intro
4/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
4
trade and defence for the four countries of the UK. Government in Westminster is also
responsible for health, social care and education in England, but these areas are devolved
for Northern Ireland, Scotland and Wales.
As a result of devolution, each country of the UK may have different parties in power, with
the possibility of increasing powers in the future. The impact of this is the diversification of
policy and direction of travel.
Legislative drivers
The main areas of UK-wide legislation that are relevant include the following themes:
Human Rights
Disability Discrimination
Equality
Though there is different local interpretation, these far-reaching legal instruments define
the rights and responsibilities of people and those commissioning and providing servicesfor them.
Public protection has also been strengthened through the introduction of registration of
professionals, for example, through the Health Professions Council.
There is separate legislation relating to health, education and social services in each of the
devolved administrations in England, Northern Ireland, Scotland and Wales.
Economic
The current challenging economic backdrop will have a significant impact on the financingof public services, with local planners and commissioners prioritising services which are
value for money, evidence based and releasing cash through innovation.
Social
In order to plan and deliver services, it is essential to identify the demographic factors
relevant to speech and language therapy (SLT) and the challenges that these bring.
The population is aging: people are living longer.
The birth rate is falling: most families are having fewer children The infant mortality rate is also falling, with more children surviving premature birth or
health problems or injury in infancy.
The urban population is growing.
The proportion of the population in employment is falling.
The proportion of the population with English as an additional language is increasing,
particularly in urban areas.
-
8/16/2019 Aac Plus Intro
5/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
5
THE NEAR OR LOCAL CONTEXT
Localised policies
Central to the new reforms is the emphasis on local decision-making within a national
framework. Across the four countries of the UK there are requirements to provide services
to accord with local need and influence. In England there is a particular focus on
increasing the range of potential providers (plurality of provision) with commissioners
having a role to stimulate the market.
For each country, arrangements have been established to assess whether commissioners
are achieving better health outcomes for the local population. Part of this process will be
an assessment of how well commissioners are performing against specified
competencies/indicators/targets. For example, in Northern Ireland these targets are based
upon high-level outcomes linked to local strategies.
With the devolution of power to local levels, there is a focus on developing more robustaccountability. There is an emphasis on joint working to support integrated commissioning,
service planning and provision across health, social care and education.
There are different approaches to this development with different structures and
commissioning and performance management arrangements being established across the
UK. The dominant theme in strengthening accountability is “putting service users at the
centre” with respect to:
Access and self–referral
User voice at strategic to operational to individual case management
Population/local engagement
Information and advice for users, parents/ carers Patient Rights
Self management of conditions
Some localities will be commissioning or planning speech and language therapy services
as a single service whilst others will be commissioning integrated services, cutting across
traditional boundaries, with health services integrated with education or social services. In
many areas, this has already happened for children's services.
It is recognised that, often, no single agency can deliver best outcomes for their service
users by working in isolation. Joint commissioning is advocated wherever the meeting theneeds of individuals requires contributions from a number of agencies.
Similarly, some service planners or commissioners will be organising services around
disease groups, such as services for persons who have survived a stroke. In either case, it
will be important for speech and language therapy managers to liaise with other services
to ensure that SLT provision is incorporated in their service plans.
Special arrangements are in place for commissioning services for unusual, low incidence
or costly interventions. Speech and language therapy managers should identify the
specialist commissioning procedures that may be required for individuals requiring
-
8/16/2019 Aac Plus Intro
6/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
6
particular interventions such as costly augmentative communication aids, protracted or
intensive interventions.
Addressing local needs
In general terms, the UK is experiencing a number of long-term demographic changes
(some of which are identified above).
There is significant local variation within these general trends. It is important to understand
what these changes and variations imply in relation to the provision of local SLT services.
Other local factors to be taken into consideration include: employment, cost of living,
housing, transport and, particularly, levels of deprivation.
There are information resources available online from which planners, commissioners and
providers can find out more about local and regional demographic factors. Some of these
can be found signposted on the RCSLT website www.rcslt.org .
Local public health teams will also be able to sign-post local services to relevant data and
information for their area.
There will also be learning from data collected by services. The RCSLT has developed an
online tool called Q-SET, the Quality Self- Evaluation Tool to help you collate local SLT
service derived information http://www.rcslt.org/resources/qset . Q-SET should be used
alongside national and local data to support service planning and evaluation of service
delivery.
Through completing Q-SET, provider services can:
use the resource every 9-12 months to review progress in meeting action plans and todemonstrate service enhancement
compare their service with other similar service types e.g. urban, rural, acute,
community, adult, paediatric, education, 3rd sector
demonstrate that their service meets the needs of the service users
identify areas of strength and generate action plans relating to areas of development.
submit the results as part of the evidence for a clinical audit
retain ownership of the monitoring and development of services ensuring that strong
professional standards are maintained in the context of multi-agency teams
Service providers completing Q-SET will support commissioners to: reduce the ‘postcode lottery’ of service availability and quality
have high quality information that is relevant and accessible
have an overview of developments, trends and initiatives within the service
have accurate and timely statistics to support performance management and
monitoring
collect data to contribute to the debates on benchmarking. Where benchmarks do not
yet exist Q-SET will enable Commissioners to contribute to this in the future
collect examples of good practice to inform other pieces of work and the development
of services as a whole.
http://www.rcslt.org/http://www.rcslt.org/resources/qsethttp://www.rcslt.org/resources/qsethttp://www.rcslt.org/
-
8/16/2019 Aac Plus Intro
7/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
7
Locally derived information will help SLT services to illustrate:
the numbers of patients/clients seen
sources of referral
amount of resource used in providing a service to the client e.g. number of sessions
and skill mix
nature and severity of the disorder, disability, psychosocial impact at the onset of
intervention
nature and severity of the disorder, disability, psychosocial impact at the completion of
intervention.
level of satisfaction with the service.
Service provision
Speech and language therapists have a role in delivering specialist and targeted support
to clients, carers and their families. Speech and language therapists can also reduce long-
term demands on services by addressing immediate needs that arise from circumstance
rather than underlying impairment. Providing training for the wider workforce is integral tothe speech and language therapists core role, as outcomes for people with speech,
language and communication needs SLCN are improved when the whole workforce is
able to contribute appropriately to care pathways.
SLTs also work with the wider workforce contributing to the public health agenda,
promoting health and well-being in respect of communication and swallowing. There is
little awareness outside the profession of the role of speech and language therapists in
preventing the development of speech and language impairments and the further impact
and consequences of different speech, language and communication disorders upon
health, education, social integration and employment.
The challenges of meeting the speech, language and communication needs (SLCN) of a
given population are best understood through a social (participative) model. Key elements
of a total service specification will start with:
identifying the needs of the service user, parent or carer for support and information
identifying/assessing and diagnosing specific SLCN and providing appropriate
intervention.
considering needs of service users within the environments they encounter
training the wider workforce that interfaces with them to maximise opportunities for
positive outcomes.
The balanced system (diagram 1) below illustrates the wider context for how SLTs
contribute to this range of activities. The needs of service users should be considered in
service specifications. The role of SLTs in supporting the active participation of service
users in service planning, adapting the environment and enskilling the workforce is as
relevant as the SLT role in identification and intervention.
-
8/16/2019 Aac Plus Intro
8/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
8
Workforce
Careful planning of services, including joint commissioning, will help to shape the
workforce and inform the skill mix required to deliver high quality services, improve
outcomes and support value for money. Because the commissioning and planning of
services relies on the evidence base for a given type of SLCN or model of practice, it isessential that clinical and managerial expertise from speech and language therapists is
available to support innovation and quality of service design.
Speech and Language Therapists, as part of the wider workforce, may be employed by a
range of organisations, including the third sector, social care and education or be working
as private practitioners.
Equal Access to services is of importance to local decision makers. Local demographic
profiling will inform workforce requirements. For example, bilingual staff and support
workers are required in most areas to meet the needs of diverse communities. Theappropriate skill mix should enable services to be family-centred and be culturally and
linguistically appropriate and responsive. It may be necessary to consider increasing home
delivered services or providing services in unusual locations.
The RCSLT also acknowledges the important role that Assistants and Support Workers
have in the delivery of effective speech and language therapy services. Assistants and
Support Workers are integral members of both speech and language therapy and multi-
disciplinary teams, engaged in a wide range of clinical settings with diverse client groups,
duties and responsibilities. http://www.rcslt.org/aboutslts/rcslt_statement_v3.pdf
http://www.rcslt.org/aboutslts/rcslt_statement_v3.pdfhttp://www.rcslt.org/aboutslts/rcslt_statement_v3.pdf
-
8/16/2019 Aac Plus Intro
9/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
9
In order to support more effective use of skill mix, SLT services also need to provide
education and training of the wider workforce and not be focussed solely on direct patient /
client care. For all services, this is critical to secure the appropriate balance of cost-
effective universal, targeted and specialist services.
PRACTICAL CONSIDERATIONS
Many people involved in strategic planning, commissioning or reviewing services will not
be familiar with speech and language therapy, its objectives, the needs of clients requiring
speech and language therapy, the principles driving the profession, or the evidence base
and the following points may support people.
Where possible, draw on the evidence base.
Communicate clearly and succinctly. Avoid using acronyms and provide a glossary of terms.
Do not assume knowledge of local arrangements or the requirement to interface with
other agencies
Set your service in the context of local priorities.
The RCSLT’s Communicating Quality 3 (CQ3) provides clear guidance on care pathways,
clinical standards and issues related to quality assurance. This information should be used
in submissions to support commissioning quality services.
The following guiding principles have been adopted and apply to all client groups. Services
are to:
-
8/16/2019 Aac Plus Intro
10/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
10
be family centred and culturally and linguistically appropriate and responsive
be comprehensive, coordinated and team based
work with and communicate effectively with other services meeting the needs of the
client
be evidence based
ensure equal access
involve the family and carers
include training and education of co-workers
ensure practitioners continuing professional development and appropriate support.
Evidence of the impact of the service will be important to commissioners and providers.
Providers will need to demonstrate the impact of their service, particularly when services
are being reviewed. Determining the objectives of the service will support the process of
outcome measurement. SLT services will need to provide information on outcomes
achieved and levels of client satisfaction. Some of this information can be gathered
through use of the RCSLT’s Q-SET tool, as detailed above.
Managers of speech and language therapy services will need to equip themselves to
engage effectively and positively with those who are commissioning or monitoring
services. They will need to:
identify who is commissioning or responsible for overseeing different services. For
example, health commissioners may be working with commissioners for
education/head teachers. It is important to identify who is taking the lead for each
aspect of the service delivery in the locality.
establish good working relationships and effective communication with those
commissioners and planners for their area of responsibility.
be aware of local priorities and commissioning plans and strategies.
have a good understanding of the commissioning/planning/monitoring framework forthe locality
be equipped with local data, knowledge and evidence to the tendering process
be clear of the unique contribution of the service to improving health, employment,
education and social outcomes
be able to clarify and demonstrate local working partnerships and collaborations
provide data describing the service provided, (numbers and types of patients, numbers
of attendances, health and social outcomes etc).
The RCSLT has developed a range of resources to support its members with Continuing
Professional Development. CPD is a regulatory requirement for all SLTs and this requiresall HPC Registrants to demonstrate how the CPD they have undertaken has sought to
enhance service delivery and to be of benefit to service users. The RCSLT has endorsed
this requirement through its own CPD standards. http://www.rcslt.org/cpd/resources
http://www.rcslt.org/cpd/resourceshttp://www.rcslt.org/cpd/resources
-
8/16/2019 Aac Plus Intro
11/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
11
THE EVIDENCE BASE
The commissioning and planning of services must be informed by the evidence base of
effective practices.
This Resource Manual SLCN is based on a synthesis of existing published research. The
threshold for inclusion in the syntheses has favoured the most scientifically robust
research methodologies which have often reflected medical (impairment) rather than
social (participative) models of care.
In the section summaries, emerging practices that have not been included in the evidence
synthesis, are referred to and should be considered alongside the syntheses. This tension
between empirical evidence resulting from robust research, which by definition is
retrospective, and the needs to encourage innovation and service re-design to support
improvements in outcomes for people with speech, language, communication and
swallowing difficulties is natural and unavoidable. Emerging practice will not have the
same evidence base and therefore less empirically stringent measures of evidence needto be taken into account for these areas including professional consensus and measures
of service user, parent or carer experience. However, because of the value of some
emerging innovative practice, they have been included in this resource.
An overview of the methodologies employed in identifying practices that are included in
this resource accompanies this document.
Using these resources
Speech and language therapy managers can assist commissioners by understanding their
agenda and the objectives that they are to be assessed on.
The Royal College of Speech and Language Therapists is providing these resources to
assist speech and language therapists in gathering the core data required to support
service tendering agreements, service planning, monitoring arrangements and/or where
services require specification.
Each part of these resources is focused on a specific area.
The resources provide:
The Contextual Synthesis. This includes definitions, information on the incidence and
prevalence of the disorder, key contribution of speech and language therapists,
consideration of the implications and broader consequences of the disorder.
The Synthesis of Key Literature. This summarises the evidence of the impact of
speech and language therapy.
Each section within these resources gives succinct information to inform the factual
content for any service planning activity. These include:
Key points
Topic –What is [the condition]?
How many people have [the condition]?
-
8/16/2019 Aac Plus Intro
12/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
12
What causes [the condition]?
How does this condition affect individuals?
What are the aims/objectives of speech and Language therapy interventions for [this
condition]?
What is the management for people with [this condition]?
What is the evidence for Speech and language therapy interventions in [this
condition]?
Studies
Assessment methods
Speech and language therapy interventions
Summary
References
This information will need to be put into context, using local information.
Other guidance and resource materials
It is recognised that service managers may wish to amplify or clarify, an aspect of their
service by providing reference to other national or local research of relevance.
The RCSLT has a range of resources which can be used to further support and inform the
commissioning, planning and provision of services for people with speech, language,
communication and swallowing needs. These can be found on the RCSLT website:
www.rcslt.org
The RCSLT is grateful to the experts from within the SLT community who
contributed to the evidence published in this document.
http://www.rcslt.org/http://www.rcslt.org/
-
8/16/2019 Aac Plus Intro
13/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
13
METHODOLOGY FOR SYNTHESIS OF LITERATURE
Introduction
The focus of the interventional synthesis within these briefings is to provide a synopsis on
the effectiveness of speech and language therapy interventions for each specific condition.
The interventional syntheses are produced by reviewers within the Information Resources
Section (within the Health Economic and Decision Science Section) at the School of
Health and Related Research (ScHARR). Information specialists/reviewers for this bulletin
were Diana Papaioannou and Anna Cantrell.
Methodology
The interventional syntheses are not intended to be a full systematic review within each
topic area. However, they draw upon systematic review techniques to ensure that the
syntheses are developed according to systematic, explicit and transparent methods. Theintention of the syntheses is to consolidate twenty articles which represent some of the
best research for each topic area.
Literature searching
Systematic literature searches were undertaken to identify a range of evidence for each
interventional synthesis. The interventional syntheses do not attempt to consolidate all
research within a particular topic area; rather they aim to present a careful selection of the
most current research within that field. Therefore, the approach adopted for the literature
search aims to be comprehensive reflecting this systematic and explicit approach.
Firstly, search terms were selected within the project team drawing on the expertise of four
speech language professionals. This involved listing all possible synonyms describing the
condition or population (for e.g. children/infant, stuttering/stammering) and combining
those with terms to describe speech and language therapy. Terms were used in both free
text and thesaurus searching. The following databases were used:
ASSIA
CINAHL
The Cochrane Library (which includes the Cochrane Database of Systematic Reviews,
Cochrane Central Register of Controlled trials, Database of Abstracts of Reviews ofEffects, Health Technology Assessment Database and NHS Economic Evaluations
Database).
Linguistics and Language Behaviour Abstracts
MEDLINE
PsycInfo
All references retrieved from the literature searches were entered onto a Reference
Manager Version 11 database using appropriate keywords.
-
8/16/2019 Aac Plus Intro
14/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
14
Selecting and obtaining relevant articles
Articles for inclusion were selected to illustrate the range of good quality evidence within
each topic area. An initial screening of articles was undertaken by the Information
specialists/reviewers who adopted the following principles:
Articles must be empirical research evaluating the effectiveness of a particular speech
and language therapy intervention
Only articles published in English language are included.
In general, only the most current (1998-present) literature is included. However,
exceptions were made to this if a particular article was felt to be important to include.
Where possible higher level evidence was included (systematic reviews, randomised
controlled trials). However, this research did not always exist in every topic area.
Efforts were also made to seek out literature that provided a range of perspectives on
interventions for each topic area, i.e. both quantitative and qualitative research.
Following initial screening, the remaining articles were examined by two members of theteam; each having considerable speech and language therapy knowledge and experience.
Approximately, twenty articles were selected by the two reviewers with disagreements
being resolved by a third reviewer.
Assessing the quality of relevant articles
Formal quality assessment of the articles was not undertaken. Instead, quality assessment
involved using checklists as a guide to give an indication of the overall quality of studies
and highlight the main good and bad aspects of each study. For each interventional
synthesis, the included study designs are listed and the problems with each study design
noted. General observations on study quality are made and common errors within thestudies, where appropriate, are specifically noted. The checklists used are one for
quantitative and one for qualitative studies from the Alberta Heritage Foundation for
Medical Research.1 Additionally, when an identifiable study design was used, the
appropriate Critical Appraisal Skills Programme (CASP) checklist was selected.2
Syntheses of the twenty articles
Each article was read in turn by one of the Information Specialists/reviewers. The key
points were summarised including the objective of the study, the participants’
characteristics, the methodology, the intervention, results and limitations. From this,articles were grouped into themes according to the factor being investigated (for e.g.,
length of intervention, personnel carrying out intervention, family involvement in treatment,
nature of disorder). Results were summarised and drawn together within each particular
theme and a summary paragraph provided at the end.
These syntheses first went out for review by selected individuals, identified by the
research team, with particular expertise in the delivery or management of services to the
1 LM Kmet, RC Lee, LS Cook (2004) Standard Quality Assessment Criteria for Evaluating Primary Research
Papers from a Variety of Fields. Accessed at http://www.ihe.ca/documents/hta/HTA-FR13.pdf (Accessed on25
th September 2008, now no longer available)
2 Critical Appraisal Skills Programme (2007) Appraisal Tools. Accessed athttp://www.phru.nhs.uk/Pages/PHD/resources.htm on 9
th January 2009.
https://webmail.shef.ac.uk/horde/util/go.php?url=http%3A%2F%2Fwww.ihe.ca%2Fdocuments%2Fhta%2FHTA-FR13.pdf&Horde=d671418123b6f29c44085d4d9d054e27http://www.phru.nhs.uk/Pages/PHD/resources.htmhttp://www.phru.nhs.uk/Pages/PHD/resources.htmhttps://webmail.shef.ac.uk/horde/util/go.php?url=http%3A%2F%2Fwww.ihe.ca%2Fdocuments%2Fhta%2FHTA-FR13.pdf&Horde=d671418123b6f29c44085d4d9d054e27
-
8/16/2019 Aac Plus Intro
15/42
Resource Manual for Commissioning and Planning Services for SLCN
© RCSLT 2009
15
specific client group. Comments were included in the second draft, which was then
dispatched to those selected by the Royal College Speech and Language Therapists who
were invited to attend a focus group day. These therapists gave detailed consideration to
their specialist area and contributed to the more general discussion of one further area.
Issues to be captured in the key points were also identified within the focus groups. These
comments contributed to the third draft of the syntheses, which again went out to
reviewers. In some cases, further work was required in order to modify the wording and
reflect discussion.
Checklist for service managers involved in commissioning services
Have you presented incidence and prevalence figures and local demographic trends for theconditions in your area?
Have you provided information on local access and use of services in the context of the numberexpected and highlighted your approaches to inequalities?
Have you consulted systematically with users to inform development of this commissioningproposal?
Does your proposal fit/link with local cross agency priorities?
Have you outlined the range of services provided including training?
Have you made clear how this fits with future planning for your service over the next 3-5 years?
Have you stated the assumptions which underpin your thinking in the plan and for futuredevelopments?
Have you offered predictions about the likely impact of investment in the proposal?
Have you made clear where the risks are and what contingency plans you have put in place?
Professor Pam EnderbyDr Caroline PickstoneDr Alex JohnKate Fryer Anna Cant rellDiana Papaioannou
-
8/16/2019 Aac Plus Intro
16/42
RCSLT RESOURCE MANUALFOR COMMISSIONING ANDPLANNING SERVICES FORSLCNAugmentative and Alternative
Communication (AAC)
-
8/16/2019 Aac Plus Intro
17/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
2
Augmentative and Alternative Communication
1. Key Points
1. AAC should
be
considered
as
a viable
option
for
improving
the
quality
of
life
of
anyone
of
any
age with a severe communication impairment resulting from developmental, acquired,
progressive, long‐term or acute conditions.
2. Speech and Language Therapists (SLTs) are specialists in communication difficulties and as such
are an integral part of multidisciplinary teams that support AAC assessment, provision, use,
training and support.
3. SLTs who have had specific basic training on AAC acquire a basic competence in assessment and
provision of AAC and require access to and support from specialist services for those people
needing more in depth assessment and provision.
4. The provision of AAC can assist children and young people with severe communication
problems to develop cognitive, receptive and expressive language, and literacy skills.
5. AAC needs to be introduced at the appropriate time for all those who have a communication
impairment in order to improve quality of life, learning and communication opportunities.
6. AAC needs to be introduced at the appropriate time for persons with progressive neurological
disease affecting their speech. Access to regular review of these individuals is required to
ensure that any systems are adapted with their changing needs and abilities.
7. AAC can reduce frustration, improve autonomy and reduce strain of those with a severe
communication impairment and their carers and communication partners.
8. AAC low and high tech communication aids/systems can assist those patients in intensive care
units or high dependency units to communicate whilst other channels are unavailable to them.
9. AAC users themselves identified the need for one‐to‐one therapy to improve linguistic and
functional competencies as a priority.
10. All users of AAC should have access to regular reviews by a specialist team, allowing updating of
their systems.
11. Services should allow for equipment to be tried by potential users of AAC prior to provision or
purchase.
12. Appropriate training and support on AAC systems and strategies are needed for successful use.
13. Speech and language therapists need access to regular training on AAC to keep them informed
of technological changes and new methods of implementation.
14. Maintenance of equipment should be incorporated in service provision.
2. What is Augmentative and Alternative Communication?
The term ‘Augmentative and Alternative Communication’ (AAC) has been defined by International Society
for Augmentative
&
Alternative
Communication
(ISAAC)
‘to
describe
extra
ways
of
helping
people
who
find
it hard to communicate by speech or writing. AAC helps them to communicate more easily.'
-
8/16/2019 Aac Plus Intro
18/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
3
Therefore, AAC is a functional definition for systems that aim to help people with communication
impairments to communicate more effectively (Loncke et al. 2006). Communication difficulties may stem
from physical, sensory, intellectual, learning or cognitive disabilities. People who use AAC (pwuAAC) have
unique needs that require AAC to be customised to meet their specific communication needs, physical and
cognitive abilities within their personal context. Communication needs usually necessitate the pwuAAC to
employ a combination
of
several
different
AAC
strategies.
Communication
includes
more
than
just
giving
someone a message, but needs to allow a person to initiate and end interactions, maintain different topics
of conversations, make requests, relate information and allow a historical narrative to be maintained.
Thus AAC strategies can help a person communicate wants, needs, thoughts, and ideas when that person is
not able to use speech. The AAC strategies usually include both unaided and aided methods of
communication. For descriptive purposes aided communication systems can be divided into two systems,
powered and unpowered:
Communication charts, symbol levels and books with no power system.
Technology that makes use of equipment that has a power system. The device usually allows the
individual to access speech output or written output. For example, a Voice Output Communication
Aid (VOCA)
allows
the
AAC
speaker
to
communicate
using
speech
output
which
may
be
digitised
(recorded) speech or synthesised speech (Schlosser et al 2003, 2007). There are a wide variety of
VOCAs available of differing shapes, sizes and weights and can store different amounts of
information in different organisations. PwuAAC with physical limitations may need to use
alternative access to operate a communication device. This may be a switch, joystick, touch screen
or eye gaze unit. VOCAs and communication software can utilise static displays where the symbols
are always on display on the device or have dynamic displays that allows the person to navigate
between many sets of symbols and across levels or pages (Beukelman & Mirenda 2005).
Table 1: Examples of types of AAC
Aided
Unaided
No power Power
Eye Pointing Symbol/Pictures/ Charts/
Books Dedicated computer systems
Facial expressions Communication passport Voice recognition software
Pointing Etran frame Software for non‐dedicated computer systems
Gesture Pointer Voice Output Communication Aids
Signing Paper and pencils Assistive Technology Systems with voice
AAC can be seen as comprising of 4 strands:
The manner of communication (e.g. medium used such as Speech Generation).
The means of access to the medium (e.g. keyboard, touch screen, switch).
A system of representing meanings (e.g. words, signs and symbols).
Strategies for interaction (e.g. having a conversation using the AAC) (Communicating Quality 3 2006).
AAC systems include unaided and aided methods of communication:
Unaided Communication includes “techniques that do not require the use of an external object”
(Glennan & Decoste 1997) and includes gesture and signing, facial expression, and pointing.
Aided Communication involves “the use of physical objects, typically referred to as aids or devices
which are used to communicate messages” (Glennan & Decoste 1997). Aided communication
-
8/16/2019 Aac Plus Intro
19/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
4
includes communication charts and books, pen and paper, Voice Output Communication Aids
(VOCAs). Symbols can include objects, photographs, line drawings, detailed pictures, coloured
symbols, geometric shapes, gestures, manual signs, letters, or words. Symbols can be organised in
many different ways, but will always be organised into a system that suits the AAC speaker.
Those AAC
systems
that
are
described
as
unaided
include
the
use
of
signs,
gestures,
facial
expressions
and
eye pointing, none of which requires equipment or technology. AAC systems that are described as aided
include use of additional equipment such as pen and paper, pictures/photos, communication books, and
symbols. Symbols can include objects, photographs, line drawings, detailed pictures, coloured symbols,
geometric shapes, gestures, manual signs, letters, or words and be organised across a board or into layers.
Technical devices usually allow the individual to access voice/speech output or written output. VOCAs can
utilise static displays where the symbols are always on display on the device or have dynamic displays that
allows the person to navigate between many sets of symbols and across levels or pages (Beukelman &
Mirenda 2005). The physical design of the devices can come in differing shapes, sizes and weights and can
store different
amounts
of
information.
Those
people
with
physical
limitations
may
need
to
use
different
access methods such as using a switch or switches to operate a communication VOCA depending on their
abilities.
AAC strategies can promote social inclusion and facilitate participation so that individuals can maintain or
develop communication in different settings. An unaided AAC system can be used in any environment. It
is spontaneous and facilitates communication between the pwuAAC and their regular communication
partner. However, it must be noted that, an unaided system requires a communication partner to
understand the person’s communicative meaning and the communication may not be understood by those
people who are less familiar with the method. The use of aided communication in the form of VOCAs can
facilitate communication
to
a wider
group
of
people
and
across
more
communication
settings
which
can
increase independence, particularly for those with severe physical and communication difficulties. For
example, an individual can sustain conversations, use the telephone, use electronic communication
systems, send e‐mails, and use Twitter, Facebook, Blogs and message boards as well as participating in
education and work settings.
Speech and Language Therapists (SLTs) are specialists in communication difficulties and as such are an
integral part of multidisciplinary teams that support AAC assessment, provision, use and support.
3. How many people use Augmentative and Alternative Communication?
The conditions that are associated with the requirement for AAC use may be developmental or acquired.
The developmental conditions include: cerebral palsy; autism; learning difficulties/disabilities; and
developmental apraxia of speech. Acquired conditions include: head and neck cancer; acquired
neurological conditions, such as, stroke or head injury and progressive neurological conditions, such as,
motor neurone disease; multiple sclerosis; Parkinson’s’ disease and degenerative cognitive conditions such
as dementia. AAC is also relevant for patients in Intensive Care Units.
It is difficult to obtain specific figures of prevalence of AAC use because of the diversity conditions and the
different manner of funding of AAC. Prevalence varies with the condition reported and the under‐
identification of
potential
AAC
users.
For
example,
a report
on
AAC
use
in
children
aged
0‐19
years
in
England identified an under‐identification of children who could benefit from using AAC (Gross 2010). The
population requiring AAC systems is likely to increase with the increased survival rate of people with
complex difficulties and the development of new AAC systems that can help a wider population, such as in
-
8/16/2019 Aac Plus Intro
20/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
5
Autism and Dementia. For example, a study by Parrott et al (2008) reported that the numbers of young
people aged 15‐19 years who had a severe or complex needs had increased by 70% in the period 1998 to
2008. The figures in table 2 provide an indication as to the prevalence of use of AAC in general and in
some specific populations. Incidence is less relevant when talking about AAC use, as it is difficult to
pinpoint ‘new cases’.
Table 2: Prevalence of AAC
Population referred to Prevalence Source
Children and young people
needing high technology AAC
in UK
0.05% or 6,200 Gross 2010
Projected adult prevalence in
UK
19,710 Gross 2010
Projected need for AAC in
England
61,792,000 in
UK
population
370,752
using Scope figure 0.6%
Office of National Statistics 2010 mid
2009 figures for UK & Scope estimate
2006
UK population who would
benefit from AAC
0.4‐1%
0.6% most quoted
Scope 2007
People in UK and USA who
require AAC systems
0.3‐1.4% From studies in UK and America,
including Beukelman and Ansel 1995,
cited in Communicating Quality 3
2006 RCSLT
School population in UK
needing AAC systems
0.2‐0.6% Blackstone 1990, cited in
Communicating Quality 3 2006 RCSLT
Children with Special
Educational Needs
statement
referred for AAC
18% Wright J, Clarke M, et al. 2004.
People with cerebral palsy
using AAC
Male 61%
Female 39%
Low tech 50%
Only use in formal
contexts 22%
Murphy J et al. 1995.
People in USA using AAC
systems
8‐12 per 1000 people Studies reported in ASHA 2008
edition.
Cerebral palsy resulting in a
speech impairment
needing
AAC support
31% to 88% Beukelman & Mirenda 1998.
4. Who uses Augmentative and Alternative Communication?
Individuals who experience communication problems as a result of their speech, language and
communication difficulties may benefit from using a range of AAC strategies. Table 3 shows examples of a
range of developmental and acquired conditions associated with communication difficulties in adults and
children by age groups who may benefit from AAC to facilitate communication.
-
8/16/2019 Aac Plus Intro
21/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
6
Table 3: Examples of aetiological conditions of associated with AAC use for both adults and children
Child Group
Acquired
neurological
e.g.:
Stroke
Head Injury
Progressive neuromuscular e.g.:
Freidrich’s Ataxia, Complex Syndromes,
Muscular dystrophy
Congenital conditions e.g.:
Cerebral Palsy
Multiple Complex Disabilities
Profound and Multiple Learning Difficulties (PMLD)
Physical Difficulties
Developmental disorders e.g.:
Learning Difficulties/Disabilities
Autistic Spectrum
Developmental delay
Speech and Language Impairment
Adult Group
Acquired neurological
e.g.:
Stroke
Head injury
Progressive neuromuscular e.g.:
Progressive Neurological: Multiple Sclerosis, Motor Neurone Disease, Parkinson’s disease
Muscular Dystrophy
Changes to laryngeal and oral pathology e.g.:
Voice
Head and
Neck
Cancer
Congenital conditions e.g.:
Cerebral Palsy
Cleft Palate & craniofacial malformations
Syndromic conditions
Profound and Multiple Learning Difficulties (PMLD)
Adults with Physical Disabilities
Adults with Learning Disabilities
Adults with Autism
Degenerative Neurological conditions e.g.:
Dementia
-
8/16/2019 Aac Plus Intro
22/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
7
Individuals with aetiologies that give rise to complex communication difficulties can benefit from different
AAC systems strategies and equipment to support their communication needs. Communication needs vary
greatly in respect to the physical and cognitive abilities present. For example, a person with physical
difficulties who cannot point will need alternative access, such as, using eye gaze to look at photos,
pictures, symbols or words. A person who cannot use a keyboard or touch screen may need to use one or
more switches, use a joystick instead of a mouse or eye gaze technology.
There may be a need for the use of AAC systems on a short term basis, when the person has limited
communication due to delayed development or surgery. Persons with cognitive difficulties and limitations
in speech or language, but where the ability to understand and formulate language is adequate, may
benefit from an AAC system which makes use of graphic symbols and voice output. Individuals with
lifelong developmental disabilities that affect communication may use AAC strategies to augment their
speech or as an alternative means of communicate (Mirenda 2003). If language, reading or writing abilities
are not
present,
or
not
yet
developed,
then
an
AAC
system
will
need
to
be
chosen
that
uses
the
appropriate level of understanding and developmental level of language.
Persons with cognitive difficulties may be able to access AAC systems, strategies and equipment but may
need more support with language structure and organisation. For example, the person may use signing or
need graphic symbols to represent whole or partially complete utterances. If reading or writing abilities
are not present, delayed or lost, then a graphic symbol system will be needed in a communication book or
chart or on a Voice Output Communication Aid (VOCA). In selecting any AAC system, strategy or
equipment, the cognitive, visual, and physical abilities of the individual’s needs must be considered.
5.
How
does
use
of
an
Augmentative
and
Alternative
Communication
system
impact
on
individuals?
The use of an AAC system strategy or equipment provides a means of communication for people with
asevere communication impairment. The impact of using AAC systems, strategies or equipment varies
with the individual circumstances and needs of the person, the level of speech and language impairment,
communicative ability of the individual to facilitate their participation in society. Having an adequate
communication system or equipment affects a person’s ability to make choices and their overall quality of
life (Bush & Scott 2009, Hamm & Miranda 2006).
The introduction of an AAC system, strategy or equipment can lead to the development of language and
cognitive abilities,
provided
the
most
appropriate
tools
are
used
(Millar
et
al.
2006,
Beukelman
&
Mirenda
1998). There is also a strong relationship between speech and literacy skills. However, some highly skilful
AAC speakers are unable to read. “The development of literacy skills in a person will open up a wider
choice of AAC options” (Beukelman & Mirenda 1998, p356). Parents often report that communication
systems, strategies and equipment play an important developmental and educational role.
People who have an acquired speech difficulty are usually older and of an age when speech is partly or
fully functioning and use speech as their primary means of communication and with a lifestyle that
depends on ‘spoken communication'. Whether having suddenly lost speech due to a trauma, or gradually
losing speech due to a progressive neurological disorder, AAC can be used to replace or support speech
based communication.
AAC
systems,
strategies
and
equipment
will
inevitably
be
more
restricted
than
being able to speak. The levels of frustration at not being able to express themselves easily will have an
immense impact on someone’s lifestyle and communication partners.
-
8/16/2019 Aac Plus Intro
23/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
8
Hodge (2007) reporting on a project exploring the experiences of pwuAAC, found that obtaining a
communication aid can transform someone’s life, increasing independence and access to opportunities,
helps the user to interact with those around them. Even for users who do not describe their experience in
such life changing terms, AAC strategies can still be indispensable at specific times, such as, hospital
appointments or communicating over the telephone.
If the introduction of appropriate AAC systems, strategies and equipment is delayed there may be
difficulties in:
social interaction
control of environment
development or restoration of language skills
initiating communication
learning
developing life skills
participating in education and employment
This in turn may lead to:
lack of or loss of identity
depression
passivity/learned helplessness
reduced learning opportunities
isolation
challenging behaviour
risk of harm or abuse
failure to reach potential in life (Communicating Quality 3, 2006).
6. What are the aims/objectives of Speech and Language Therapy interventions for Augmentative
and Alternative Communication?
SLTs are communication specialists who can provide an assessment of communication needs,
identify areas for intervention and recommend/teach communication strategies to enable people
with communication difficulties to maximise their potential.
SLTs provide person centred approaches, aiming to observe the communication abilities and
restrictions of the person their communicative needs and observing when a communication is
successful or where it breaks down. The aim of intervention is to find ways of making that person a
more successful communicator and where possible to be communicatively competent.
The SLT will aim to incorporate different communication approaches that best meet the
communication needs of the person. This will usually include several different methods of
communication and incorporate both unaided and aided methods.
The SLT involved in providing and developing communication using AAC strategies should have
experience of working with AAC or be working and consulting with a SLT who is a specialist in AAC.
The SLT
involved
in
providing
and
developing
communication
using
AAC
strategies
must
know
when
to refer on to an appropriately skilled colleague and/or a regional AAC Service.
-
8/16/2019 Aac Plus Intro
24/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
9
Standards for AAC Services have been written by Communication Matters and are available on
www.communciationmatters.org.uk
All AAC systems, strategies and equipment need to be continuously reviewed by the treating SLT
and/or local AAC specialist who are able make appropriate revisions, if necessary, so the changing
needs of
the
client
are
met.
Clients
who
are
no
longer
actively
involved
with
AAC
or
SLT
services
should have information on when and how to access an SLT review of AAC needs should this be
required. For clients unable to contact services directly, a review date should be set.
The multidisciplinary team has the specialist expertise to assess, trial provide suitable AAC.
Furthermore, all AAC systems needs to be continuously reviewed by the team and revised, if
necessary, so that it can continue to meet the changing needs of the client.
The SLT aims to provide a service that meets the needs of the individual and their family. Aims and
objectives will vary accordingly. The aims and objectives of using AAC with a person will depend on the
stage of
life
the
person
is
at:
Pre‐school – to develop vocabulary, language and interaction with family members and main
communication partners, access the Early Years Curriculum and facilitate language development.
School age – to develop vocabulary, language and interaction with peers as well as to access the
curriculum.
Throughout life – developing emotional and social skills, independence and achieving social and
vocational goals (Light 1989).
Congenital communication impairments/Developmental disorders
Children with communication impairments requiring AAC need to have systems, strategies and equipment
that take
into
account
the
need
to
support
the
development
of
understanding
(input)
as
well
as
output.
The child needs to see and hear people in the environment using his communication system, strategies and
equipment. Modelling is key to the development of first spoken words, and this is built on the ability to
understand what is said and how the message is created. Intervention with children will depend on the
relationship between understanding and spoken language, symbols and referent (Smith 2006).
Acquired communication impairments
Both children and adults can acquire a speech or language impairment associated with disease or trauma.
The aims and objectives of introducing AAC to a child or an adult with an acquired communication problem
relate to maximising the communicative function in those areas of life that are seen as a priority by the
person and
to
continually
review
the
changing
needs
of
the
person
as
their
environment
and
opportunities
alter.
Progressive neurological diseases
People with a progressive neurological disease affecting their speech may benefit from a broad range of
AAC systems. These may require adapting or changing throughout the course of the disease. For example,
an individual may benefit from a voice amplifier at an earlier stage of the disease, but at later stages, they
may require a sophisticated switch and symbol system. Case studies indicate that introducing AAC at an
early stage is beneficial and that regular reviews are required along with training of communication
partners.
AAC assessment
The aim of an AAC assessment is to identify the most effective means of communication possible for the
person. This will often necessitate a multimodal approach if the person is to communicate for different
-
8/16/2019 Aac Plus Intro
25/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
10
purposes and in a variety of contexts and environments. AAC assessment should be carried out with the
experienced SLT as part of the team. Communication Matters have created the AAC Service Standards to
include Assessment (see www.communicationmatters.org.uk)
It is necessary to:
identify participation
and
communication
needs
assess capabilities in order to determine appropriate options
identify the skills, abilities and needs of the communication partners
assess external constraints, physical and sensory challenges and abilities
find strategies for evaluating the success of interventions. (Beukelman & Mirenda 1998).
These factors are relevant when choosing an AAC system, strategies and equipment and to identify the
amount of training required to implement and support the chosen AAC systems, strategies and equipment.
It is essential for people and their communicative partners to be assessed together so appropriate and
informed choices can be made (AAC‐RERC White Paper 2011).
Table 5 shows a summary of areas to assess that uses the dimensions in the WHOICF (2002).
Table 5: WHO‐ICF dimensions ‐ summary of areas assessed by SLTs to be included in an AAC assessment
ICF dimension Areas Assessed
Impairment Physiology – motor (gross and fine motor control), sensory, auditory, and
gaze/visual function and limitations
Structures – structural integrity
Cognition – language, processing, memory, attention, concentration, perception,
mood function and limitations
Activity
Intelligibility
Use of voice in different settings
Communication abilities
Communication behaviours
Organisation of communication
Use of communication
Literacy
Factors/help needed to facilitate achieving successful communication
Ability to communicate in different contexts and locations
Ability to be understood by familiar and unfamiliar communication partners
Ability to
communicate
1‐1 or
in
groups
Motivation
Learning behaviours
Use of gross and fine motor skills
Fatigue level
Technical knowledge/use of technology/computer use
Participation Integration
Abilities, needs and preferences of communication partners
Social participation ‐ participation in differing context and settings
Life areas – education, work, economic self ‐sufficiency
Environment
Requirement for portability of AAC device
Requirement for durability
-
8/16/2019 Aac Plus Intro
26/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
11
Requirement for capability of differing AAC systems
Important/intimate relationships
Environment
Assessment of the person’s own communication environment helps to identify different communication
environments and
the
communication
systems,
strategies
and
equipment
used
in
each.
Understanding
the
communication environments helps to optimise and maximise communication. Environments may
include:
close communication partners such as family members/carers and close friends
people who know the AAC speaker, such as class mates, teachers
friends they see less frequently
acquaintances
work colleagues, people they meet in everyday life, such as shop assistants, taxi drivers, strangers
to them.
The SLT notes how communication partners choose to communicate with the AAC speaker in different
environments. A person can only use an AAC system, strategy or equipment well if those around them are
prepared to accept these means of communication. The communication partner will have different levels
of understanding how AAC systems, strategies and equipment can be best used in different environments.
The amount of training required to implement and support the AAC strategy is often dependant on the
understanding of the communication partners. The person also needs to have the opportunity to
communicate and the opportunity to develop their skills on AAC and devices. The equipment used needs
to suit the environment it is used in and the person may need to suit differing strategies according to the
environment and communicative needs therein.
AAC provision
and
support
The provision of AAC services vary across the country. The SLT aims to provide an AAC system appropriate
to the needs and to give support that enables the person to access effective and timely communication
support. Following assessment, the SLT will be involved in facilitating communication competence through
training and support to develop the person’s use of AAC. The communication needs of the individual will
change over time, requiring reassessment and, in some cases, frequent adaptations to the system. Support
for the ever changing communication needs of the person can mean a life‐long input from services.
The SLT must be part of the team who assesses and prescribes AAC systems, strategies and equipment
appropriate to the needs of the individual with the communication impairment. The team (and therefore
SLT) should
provide
sufficient
support
to
enable
the
AAC
user
to
develop
effective
and
efficient
communication.
Referral for assessment to a regional specialist centre is usually subject to set criteria for that centre. The
centre staff will liaise with the local SLT and team and discuss any aspects of assessment, training and
support as required. Other individuals would need to access AAC through alternative services. As all
regional specialist AAC services have different criteria, it is important to know where to refer people for
the most appropriate support. Further information can be obtained from the Communication Matters AAC
Service Standards.
AAC Tools
for
Communication
Partners
The more familiar the communication partner is with the person’s system of communication then the
more successful communication is. Less familiar communication partners are often uncertain about how
-
8/16/2019 Aac Plus Intro
27/42
-
8/16/2019 Aac Plus Intro
28/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
13
developed further by Communication Matters to create Competencies for all those working with AAC
speakers.
Assessment Services
Assessment may
be
at
a local,
specialist
or
regional
level.
For
example,
the
assessment
team
may
be
at
the
local level with the local SLT working in association with the family. The local SLT may be supported by an
AAC specialist SLT or specialist AAC team, according to the needs of the person, the AAC needs and the
complexity of the situation that needs attention. The composition of the teams varies according to
location and how teams evolved historically. Different teams may include different professionals according
to the aim and purpose of the service. The staff may be employed by health, education, social care or
voluntary sector/charity organisations. The AAC specialist SLTs should be employed as part of the AAC
team or brought in for their expertise (AAC Service Standards for Commissioners Communication Matters
2011). For example, in a centre that assesses children, the team may comprise of a SLT, Occupational
Therapist, Physiotherapist and Assistive Technologist and other relevant professionals may be co‐opted as
needed, such
as,
teachers
or
special
needs
teachers
or
Psychologist,
while
in
an
adult
team
might
include
a
Rehabilitation or Neurological consultant.
Details of Assessment Services are set out in ‘The AAC Service Standards’ (Communication Matters
accessed 2011) which cites details of good practice for assessment for AAC systems, strategies and
equipment.
Table 5 shows an example of a care pathway for a specialist NHS AAC service. The West Midlands AAC
Team care pathway has been described here to illustrate the type of pathway that might be followed by a
person going through a specialist AAC Centre.
Table 5: Summary of an example AAC care pathway (West Midlands AAC Team)
Stage of Management Details
Referral Dependant on local factors
Assessment Gathering information from the patient including:
background to the communication difficulty
current modes of communication
use and understanding of language
equipment and positioning
communicative environment.
Planning
A plan
would
need
to
be
devised
by
a multidisciplinary
team
or
professionals
involved in the patients care, including short, mid and long term goals.
Considerable training and support is needed within schools for children, staff
and the AAC users’ peers.
Intervention Introducing an AAC system involves decisions making as to which AAC
system will be used, and if this involves a device, how this will be purchased,
instruction given, and the device maintained. This process involves input
from the user, family members, communication and education professionals
and funding agencies.
Supporting the patient in learning to use the system and applying its use in
day to
day
living
may
include:
one to one therapy
group work
-
8/16/2019 Aac Plus Intro
29/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
14
creating opportunities for communication within child’s
normal environment
introduce and develop communication strategies
training and supporting communication partners
liaise with relevant professionals
Considerable training and support is needed within
schools for children, staff and the AAC users peers 4)
Safety checks to maintain the system and resolve any
problems.
Advice and assistance with cleanliness of equipment.
Regular review
meetings
Multidisciplinary team involved in patients care.
Onward referral
process
While complete discharge from the service in unusual for AAC users, there
should be in place on onward referral process for matters which beyond the
scope
of
the
Speech
and
Language
Therapist.
The person with communication needs and their family will often seek their own solutions. This can be
because the statutory bodies cannot be supportive due to financial constraints or a lack of knowledge and
skills in the local team. At this point, the AAC speaker and/or their family or others may access information
from websites, specialist support organisations such as Communication Matters, approach manufacturers,
charities, support groups, local SLT services, Independent SLT services, GPs and other people who use AAC.
As a result, these AAC speakers may not be known to their local teams.
Local teams can be approached directly by people seeking information and advice. Many local teams have
resources that allow them to meet certain AAC needs but this depends on funding and ability to supply and
support AAC use through supplying the appropriate AAC strategy or equipment and ongoing training. This
has a significant time commitment. Referrals to a specialist Communication Aids Centre is usually via the
SLT and/or GP who will supply an assessment of impairment, abilities, participation and expectations of the
person and their family. The maintenance of the aid and repair is also a cost which will need to be met
through funding streams or by the individual themselves if no funds are available.
‘The AAC Service Standards’ (Communication Matters 2011) describe the standards for an AAC Service.
These specify what an AAC speaker can expect of an AAC Service, these include the team having the:
appropriate skills
knowledge of the full range of relevant currently available techniques and technology
awareness to know limits to their competence
ability to be objective when considering the AAC speaker’s needs
ability to carry out a person centred assessment (consider the venue, timing etc.)
skills to make person‐centred recommendations
ability to meet with individual needs and know when to refer on to another more appropriate
service
skills and knowledge to support the implementation of the communication systems.
(Taken from ‘The AAC Service Standards’ (Communication Matters 2011)
For AAC interventions to succeed certain maxims need to be remembered:
AAC systems, strategies and equipment need to be focused on the individual
individuals vary
environments vary
-
8/16/2019 Aac Plus Intro
30/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
15
communication partners vary.
The benefit of AAC is in maintaining communication, reducing frustration, facilitating social interaction and
participation in life, hobbies, interests, facilitating learning, language development, self ‐value and self ‐
worth. Developing communication skills helps to reduce feelings of isolation, anger and challenging
behaviour and
builds
self
‐esteem
and
fulfilling
potential.
Achieving
successful
outcomes,
having
an
effective and efficient communication system through the use of appropriate AAC systems, strategies and
equipment is dependent on these points (ASHA 2004).
8. What is the evidence for the use of Augmented and Alternative Communication?
What is the evidence for SLT interventions?
Evidence on SLT interventions using high technology AAC
Details of
studies
Twenty two papers were included in this summary synthesis of outcomes from high technology alternative
and augmentative (AAC) interventions. Work in non‐peer reviewed publications was excluded, and also
studies published before 2000. Study designs eligible for inclusion were those having data collected at
more than one time point, and studies having more than two participants. These quality criteria excluded
the large body of case study and cross‐sectional work in the area.
For the purpose of this work high technology intervention (“high tech”) was defined by exclusion as those
AAC methods or devices which cannot be described as low technology. Research on low technology aids
encompassed: signing; gesture; communication books; communication boards; alphabet boards; writing
and drawing;
pictures
and
symbols
not
used
in
association
with
a computer;
and
amplifiers
where
these
are not for assistive purposes. Artificial larynx aids and aids used for dysphonia were also excluded,
together with the use of aids during temporary loss of communication such as immediately post‐surgery.
The use of computers for a treatment tool/therapy only (rather than as an assistive device) was outside the
scope of the review. Technology which promotes access to computers/switches to overcome physical
disabilities was also excluded.
The scope of the population under consideration was any person who has an impairment of
communication not resulting from a primary auditory impairment. All age groups were included. The
review also considered studies reporting data from relatives/significant others of these people with
communication difficulties,
together
with
staff
delivering
AAC
services
to
this
population.
Studies
carried
out in non‐communication impaired populations were outside the remit of this review, although work
reporting findings from mixed populations was considered.
All studies were published in English and encompassed work from six different countries. The highest
proportion of papers originated from North America (12). Two papers were from Australia, two from
Germany, two from Sweden, and one each from the Netherlands and France. As will be detailed below, the
study participants included people with acquired non‐progressive neurological disorders, acquired
progressive neurological disorders, autism/autistic spectrum disorder, cerebral palsy and other
developmental disorders. High tech systems described in the included papers encompassed: voice output
communication
aids
(VOCAs)
which
are also
termed
speech
generating
devices
(SGDs);
software
on
personal computers or laptops used as a communication aid to provide voice (recorded or synthesised) or
written output; and technology providing access to personal computers or laptops enabling them to be
used as a communication aid.
-
8/16/2019 Aac Plus Intro
31/42
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
AAC
© RCSLT 2011
16
Outcomes measured
Within the papers there was a vast range of measures used to evaluate the effect of AAC intervention. This
may reflect debate in the field regarding what is considered a “good outcome” from AAC provision. Many
authors used
multiple
measures
within
a single
study.
The
outcomes
included
those
that
measured
the
number of requests or responses, the frequency of system use, accuracy of responses, correct information
units, and standardised language measures (often as part of a battery of outcomes).
Effectiveness of interventions
Acquired non‐progressive neurological disorders
Aphasia
Seven papers reported the use of high tech AAC in people who have aphasia resulting from a variety of
non‐progressive causes. The largest group concerned aphasia resulting from a cerebro‐vascular accident
(CVA).